The arguments are over; the Supreme Court decision is scheduled to be announced in June.  Whatever the ultimate fate of the Federal insurance program popularly referred to as Obamacare—be it judged unconstitutional, salvaged in whole or part, or retained in its present form—we still are going to be locked in a contentious debate about healthcare in America.  Given that we spend more than any other country in the world—far more, in fact—to achieve what are, by international standards, fairly middling results in terms of health outcomes, the questions about our patchwork system of public, private, and hybrid systems of healthcare delivery are not going to end.  We must, therefore, ask ourselves where we are now, what we hope to accomplish, and what is actually attainable within the realities of fractious ideology and fractured funding.

At the extremes of life span, the old and the young, the debate is, for the most part, not as contentious as we may be led to believe.  Although there are proposals being floated to “privatize” Medicare in whole or part and deal with preventable health problems among the young through more aggressive interventions than some might favor, no one within the mainstream of political thought is suggesting letting sick children die or denying grandpa his hip replacement.  The discussions are about cost management—which is, of course, a critical issue—but not about the question of whether necessary care should be provided.  Although scare stories meant to drive political donations are the background noise of discussions about healthcare for the young and the old, the reality is that our national conscience is not going to allow suffering among either the “innocent” young or the “deserving” elderly.  We may nibble at the margins, but we are not anywhere near to denying necessary medical care to those at the two ends of life.

The problems arise when we talk about those in the middle, those who work—or try to—and support themselves and their families while, for a variety of reasons, failing to qualify for increasingly scarce employer-provided health insurance coverage.

The original idea driving Obamacare, that everyone should be in the pool of the insured so that cost and risks can be shared among all Americans, is in obvious conflict with limited government advocates who see a requirement to purchase insurance as an unwarranted intrusion into the lives of citizens.  Whether or not the Supreme Court rules that the individual mandate, which directly mirrors the one implemented by likely Republican nominee Mitt Romney when he was Governor of Massachusetts, is constitutional, discussions about this requirement will likely continue to be both bitter and divisive for years to come.

In addition, another key provision of the contested Federal law is that insurance companies will no longer be allowed to deny coverage (or charge terrifying premiums) to those with “pre-existing” conditions—in other words, those who actually need health insurance.  Whether or not one wants to approach this issue as one of basic fairness or an inducement to purchase insurance instead of leaving providers and taxpayers to pick up the tab for care through direct payments or cost shifting, it is a provision that will largely end the practice of insuring only the obviously healthy and kicking the chronically ill to the curb to fend for themselves.

So what do we want?  Are we comfortable with permitting non-elderly adults to avoid paying for the health insurance coverage they will surely need at some point and allowing those with chronic health problems to risk bankruptcy every time they are sick?  Are we, in addition, happy to pay significantly higher prices for medical treatment in the United States due to the cost shifting care from the tens of millions uninsured to everyone else while leaving health providers at all levels to deal with questions of payment alongside questions of treatment?  Should it be the case the doctors and staff often have to perform “wallet-ectomies” to determine whether a patient has insurance at the same time they are making basic decisions about that individual’s medical care?

The questions of sharing risk and helping those with pre-existing conditions, a portion of our nation that will only continue to grow as our population grays, are without a doubt the key challenges we face as we wade through the hot rhetoric and attempt to frame solutions that are congruent with both our values and our means.  We are a fair-minded and compassionate nation, which is certainly proven by our ongoing commitments to supporting healthcare for the young and old.  However, we need to decide how to be compassionate—and fair—with those non-elderly adults who are struggling to pay for insurance, blithely ignoring the need for insurance because they are currently healthy, or are unable to find insurance because they have chronic health problems that transform them into unacceptable risks whose future healthcare and associated costs will be carried by us all through higher direct medical costs, higher taxes, and the host of evils that result from permitting untreated health conditions among our families and neighbors.

Would it be smarter, for example, to provide treatment and medication for people with diabetes so they can live the most productive lives possible—or are we better off paying for amputations and corneal transplants after their condition has been allowed to deteriorate?  Should we help someone dealing with bi-polar disorder to receive care, or are we better off allowing the condition to decline to the point where they are both unemployable and homeless?  Are we better off helping to pay the healthcare costs for those who are unable to pay for themselves through a federalized plan of insurance subsidies that puts a healthcare plan membership card in their pockets, or are we content to stick with the present system of paying for the uninsured through a combination of higher medical bills, rising taxes, and the grinding drag on our nation’s productivity of daily sending our uninsured fellow citizens out into the world weak, in pain, and desperately afraid of what the future might bring if their health problems become health crises?

This moment in our nation’s history is—arcane discussions of insurance exchanges and tax incentives aside—a gut check for our body politic.  If we decide that fear and suffering among so many of our citizens is an acceptable reality, what does it say about our values and our national character?  If we can ease off on the sound-bite shouting and begin a dialogue about what we are able and willing to do to help everyone enjoy productive and healthy lives, we likely will find we have more in common than that which we presume divides us, and we can begin the task of making thoughtful and compassionate decisions about what we owe to ourselves and our fellow citizens.

Also published in The News-Gazette (news-gazette.com) April 29, 2012